Sensory Integration

and
Chronic Schizophrenia:
Past, Present and Future
Virginia J. Hixson and
Arthur W. Mathews.

Abstract
This paper brieflyoutlines the therapy of sensory inte~ration as developed by Dr. A. Jean Ayres, including
a ~r~akdown of the most prevalent types of dysfunction. In an extensive literature review which includes
writings from 1811 through to the present day, the symptoms of schizophrenia which may be related
to.s~nsory inte~ative d~ficit are then ex?mine~. Finally: current research and treatment programs which
utll.lze sensory Integrative: treatmen~ w.lth schl~op~remcs a~e reviewed, with emphasis on a program
review conducted at Whitby Psychiatric Hospital In Ontario, 1981. Implications for future treatment
and research are explored.

Basic Sensory Integration Theory
The theory of sensory integration was developed in the
1950's by Dr. A. Jean Ayres (Ayres, 1974) and was
applied specifically to learning disabled children. Since
then, research by Ayres and others (Silberzahn, 1975;
Rider, 1978; Endler and Eimon, 1978; Larson, 1982,
Ottenbacher, 1982 etc.) has led to a continuous modifica-
tion and refinement of the theory.
Essentially, sensory integration involves taking a sen-
sation in, processing the information, and then connect-
ing this to make sense of the environment. This ability
develops in a predictable, genetically determined se-
quence, and if this is delayed or modified, sensory
integrative _dysfunction results. Such a dysfunction
hampers a: person's ability to relate to his environment,
and therefore affects his ability to adapt to the changes
required in effective daily living.
According to Dr. Ayres. "Sensory integration, or the
ability to organize sensory information for use, can be
improved through controlling input to active brain
mechanisms." (Ayres, 1974, p. 15). In treatment, the
ontogenetically earlier systems (i.e. vestibular, tactile and
proprioceptive), are given primary attention, as sensory
integration aims at promoting sequential development
and as they seem to have the most widespread effect
on general function, (Ayres, 1974; Ayres, 1974b; Barr
1979). ' if the system is functioning normally, much of the
Vestibular function:
The vestibular apparatus, strictly speaking, is part of
the proprioceptive system, however its importance is so
Virginia. J. Hixson, O.T.R., O.T.(C). Sr. Occupational therapist,
Occupational Therapy Department, Whitby Psychiatric Hospital
Whitby, Ontario. '
~rthur W. Mathews, B.Sc. (O.T.) Occupational Therapist, Occupa-
tional. Therapy Department, Whitby Psychiatric Hospital, Whitby,
Ontano.
FEBRUARY IFEVRIER 1984
p.ri~ary to sen~orr integration and its function so spe-
cialized, that It IS generally accorded consideration
separ~te fr~m that given to muscle, joint and ligament
proprioception (Bellhorn, 1972; Ayres, 1974; Ayres,
1974b; Barr, 1979). The role of this system is often
overlooked as its functions take place largely below the
level of aw~ren.ess. Sensations are evident only when
the syste~ ~s dl~turbe~ ~r when the digestive tract is
affec~ed, glvmg nse to dizziness, vertigo, nausea, a feeling
of faintness, or a 'lost in space' feeling that has been
referred to as postural insecurity, or 'primal terror'.
(Ayres, 1974; Weeks, 1979; Shaffer, 1979). The vestibu-
lar syst~m is constantly receiving input from the force
of ~ravlty and allows one to detect motion (vertical,
h~nzontal or rotary) especially acceleration and deceler-
anon, as these affect the semicircular canals in the inner
ear. The ~nstant reception of the earth's gravitational
pull helps m the development of a basic sense of security,
a sense that the ground will always be where it is
expected to be.
Proprioceptive Function and Praxis:
Pr?prioception refer~ .to information about the body
ansmg from muscle.joint and ligament receptors as well
as those associated with bone. As with vestibular input,
information received by these receptors does not reach
the level of consciousness unless attention is concentrat-
ed on it. Proprioception is critical to the motor action
by ,:"hich reflexes,. automatic responses and planned
motion occur and IS therefore basic to human survival.
Proprioception can be subdivided into a kinetic sense
(sensation of active or passive movement, an awareness
of the motion of a limb or body part) and a static sense
(a sense of position). The development of proprioception
serves as a base for the development of both praxis
and visual perception, (Ayres and Heskett, 1972; Ayres,
19
 1974; Silberzahn, 1975; Montague, 1978; Shaffer, 1979;
Resman, 1981). Without good proprioceptive informa-
tion about the extent and force of larger movement,
the development of praxis and correct body scheme is
hampered.
Ayres states:
The body scheme is basic to all motor action. It is
defined as the knowledge we have of the construction
and spatial relationship of the different anatomical
elements such as finger, legs, arms, that make up the
body. It involves being able to visualize these elements
in the movement and in different positional relation-
ships... Active motion provides the individual with
the knowledge of his physical self, how it is related
and how it can deal with space (body scheme). Motion
enables the body to learn the most about its relation
to space for motion elicits the greatest number of
proprioceptive impulses. (Ayres, 1974b, p. 52).
Poorly developed body scheme results in what Ayres
terms developmental dyspraxia. In extreme cases this
may mean the inability to unconsciously plan a simple
movement such as standing up or picking up an object
from a table. This necessitates the employment of higher
level cortical function for these low level tasks at the
expense of internal energy resources and efficiency.
In a review of neurophysiological experiments related
to cortical and subcortical integration of sensory stimuli,
Foulks (1960) found considerable evidence indicating
that if one concentrates on a motion, this has a detri-
mental effect on the quality and accuracy of that motion.
Additionally, muscles controlled by attention fatigue
rapidly. It was found that more afferent impulses were
received in the cortex when attention was not being
directed toward a movement in execution. Thus, the
neurophysiological result of dyspraxia compounds the
problem.
Visual skills and perception are also affected by poor
proprioceptive function as inadequate information from
the muscle spindles in fine occular muscles results in
poor occular control. The development of visual percep-
tion is thus inaccurate and unreliable, interfering further
with higher level learning.
Tactile Function:
Closely connected with praxis through factorial studies
is the tactile system, (Ayres, 1966; Ayres, 1971; Geddes,
1972; Ayres, 1974b).Ayres (1974; 1974b) postulates dual
functional cutaneous afferent systems -(1) a protective
system which responds to stimuli with movement, al-
tertness and a high degree of affect (often negative),
and (2) a discriminative system which is used in the
interpretation of stimuli in a temporal and spatial sense
for cognition. This duality was earlier identified by Head
(1920), who named these the "protopathic" (protect) and
the "epicritic" (discriminate) systems.
The major purpose of the protective tactile system
is to warn of potential harm and to assist in preparing
the body for defense. It tends to interpret cutaneous
stimuli as signs of danger and responds by eliciting the
emotions and physiological changes appropriate to fight
or flight and by evoking motor activity. This phylogene-
20
tically early system, when balanced by the more ad-
vanced discriminative system, continues to serve a valu-
able function in alerting the individual to close stimuli
and in preparing him (physically and emotionally) in
dangerous situations.
Adaptive behaviour and modern life however, require
more than a general alerting and a diffuse response to
danger. One must have more specific information about
the environment. If the body is constantly dealing with
touch as a warning of danger, giving necessary attention
to the finer aspects of tactile stimuli becomes impossible.
For effective function, the discriminative system must
be able to inhibit the excitation of the protective system.
Additionally however, when danger does threaten, the
person must be alerted to it and be able to respond
quickly. Ayres (1974; 1974b), postulates that the balance
of two well functioning systems fluctuates to meet the
requirements of the specific circumstances an individual
finds himself in. If the person is threatened or if the
system is malfunctioning, the protective system domi-
nates. Otherwise, the discriminative system is predomi-
nant.
Disorders in tactile perception may occur in either
system or may be noticed as an imbalance in the two.
If an imbalance exists, its most common manifestation
is tactile defensiveness which is connected with fear of
touch, increased motor activity, anxiety and withdrawal,
(Ayres, 1972; Ayres, 1974; Ayres, 1974b; Montague,
1978).
The second functional cutaneous afferent system pos-
tulated, that of discriminative touch, serves as a source
of specific tactile information about the environment.
Through the manipulation of objects and the tactile
input involved in moving objects, the individual de-
velops form and space perception and develops reliance
upon the tactile messages his system receives. Dysfunc-
tion in the discriminative tactile system results not only
in poor tactile accuracy, but also hampers the develop-
ment of body scheme, motor coordination and form and
space perception. Tasks which others find easy, e.g.
dressing, become monumental without reliable tactile
information. Self confidence and self esteem suffer.
Bilateral Integration:
Another problem related to sensory integration which
Ayres adresses is that of poor bilateral integration,
(Ayres, 1971; Ayres, 1974; Ayres, 1974b). Often linked
with vestibular disorders, the most significant charac-
teristic of this dysfunction is a tendency to use each
hand independently of the other and on its own side
of the body. Since the symptoms of this problem are
a tendency rather than an inability, this disorder is easily
overlooked. Adequate bilateral motor function requires
first of all, two acceptably coordinated extremities.
Kephart (1960) suggested that laterality (an internal
awareness of the difference between the two sides of
the body) must be learned by experimenting through
movement with the two sides of the body and with their
inter-relationship. A person with poor bilateral integra-
tion will tend to do tasks one-handedly, thereby missing
this movement experience. A true hand dominance for
CJOT - VOL. 51 - NO. I
tasks is not established. Ayres hypothesized that "the
failure to integrate function of the two sides of the body
reduces the tendency to establish one hand as the
dominant hand because the non-dominant hand per-
forms most of the motor duties on its side of the body."
(Ayres, 1974b, p. 140). The ability to use the hands
together becomes more important with increased age,
as more complex tasks are required in daily life experi-
ences. Again, the more affected a person is by this
dysfunction, the more difficulty he will have in attempt-
ing complex motor tasks and self confidence will suffer.
Sensory Integration as Related to
Schizophrenia
In his book, SCHIZOPHRENIA: SCIENCE AND
PRACTICE, Shershow (1978) includes writings of many
modern 'experts' on schizophrenia, e.g. Borus, Hollister,
Kety, Klerman, Lidz, Snyder, etc. Regarding a definition
of schizophrenia, he states: "The point, of course, is that
the definition of 'schizophrenia' has varied tremendously
throughout modern psychiatric history, not to mention
the period prior to the modern era." (p. 4). The greatest
consensus identified was that process schizophrenia, or
"poor prognosis schizophrenia" was a true schizophren-
ia.
Process schizophrenia is "characterized by a gradual
decline of activity, dullness, autism, ideas of reference,
thought disturbances, prolonged history of malad-
justment, poor physical health, difficulties at home and
in school, abnormal family relationships and somatic
delusions." (Wolman, 1973, p. 339). Another definition
of this category reads: "those forms of severe schi-
zophrenic disorders in which chronic and progressive
organic brain changes are considered to be the primary
cause and in which prognosis is poor, as contrasted with
reactive schizophrenia.'; (Stedman, 1976, p. 1259). It is
the chronic or process schizophrenic with which this
paper is primarily concerned.
Past:
Vestibular Function:
In 1811, (reprinted in 1977) Cox published case studies
describing the effect of his use of a special swing (vesti-
bular sensory input) on the treatment of the mentally
ill. Although many of his patients resisted its application
and it was sometimes seen by the patient as a punish-
ment, Dr. Cox states:
...after a very few circumvolutions a degree of change
was observed, both as to the appearance of the fea-
tures and the mind: the former expressed apprehen-
sion, while the ideas, though confused, did not seem
to crowd so rapidly... surrounding objects though they
must have appeared indistinct and confused from the
gyration, attracted the attention, and became the sub-
ject of conversation... on suspending the motion, both
mind and body in a few seconds resumed their former
morbid peculiarities ...I could detail other cases where
considerable relief was procured by swinging..." (Cox,
1977, p. 3, 4).
FEBRUARY /F~VRIER 1984
For decades the involvement of the vestibular system
in schizophrenia has been under examination. Studies
comparing nystagmus responses, (vestibular-occular re-
flex, an indirect measure of vestibular function) of schi-
zophrenics with those of the normal population were
undertaken as early as 1940 (Angyal and Blackman,
1940), and have shown this population as having a
marked deviation from the normal reaction e.g., de-
creased duration, decreased number of beats, greater
dysrhythmia (Schilder, 1933; Angyal, 1940; Freeman
and Rodnick, 1942; Leach, 1960).
With the advent of electronystagmography a small
number of studies, (Rosenblum and Friedhoff, 1961;
Levy, Holzman and Proctor, 1965) have shown
no significant difference of nystagmus response between
schizophrenic and normal populations. This may be due
to the type of schizophrenia included in the studies or
medication effects, neither of which were clearly report-
ed. Other studies using electronystagmography
continue to show differences, notably Colbert who,
when studying nystagmus responses in schizophrenic
children, found an average duration of zero. Most of
these subjects found the experience pleasurable and
none showed any sign of dizzines or nausea. Similar
results were found with caloric stimulation (Douglas,
1982). Numerous reports suggest that there is some con-
nection between nystagmus and schizophrenia.
Scientific methodology has consistently linked psy-
chosis in both children and adults with disorders in the
vestibular system (Angyal, 1940; Freeman, 1942; Ayres,
1972; Montague, 1978; Weeks, 1979; Rider, 1979). Pos-
tural reflex development and muscle tone, largely vesti-
bular traits, have been identified as irregular in many
schizophrenic people. Silver and Gabriel (1964) found
residual primitive postural responses and decreased
muscle tone in 30 out of 39 boys diagnosed as schi-
zophrenic. Endler and Eimon (1978), found comparable
results in a study with adult schizophrenic patients.
In more recent times, a cross-cultural study of tetra-
ataxiametric (four point weight bearing) patterns of stat-
ic balance in adults, by Kohen-Raz and Hiriartborde
(1979), found that the SUb-group of subjects who were
emotionally disturbed but neurologically normal was
characterized by a significantly more pronounced poste-
rior weight displacement relative to that of the remain-
ing subjects in France, suggesting differences in posture
and balance in that group. All other groups studied
across four nations showed no appreciable difference.
Schilder (1933) considered the vestibular system to
be the primary organizer of sensory information and
saw it as having a direct link with emotions through
the limbic system. Anatomically this is supported (Barr,
1979; Dimond, 1980; Douglas, 1982). Ornitz (1933) hy-
pothesized that the schizophrenic person limits his mo-
tion to avoid perceptual distortions which can be
induced in a disordered system by motion and suggests
that vestibular disturbances and disturbances of the per-
ception of one's own body are related.
Hubbard, in his study of skyjackers who exhibited
schizoprenia post-skyjack concludes:
Essentially, the skyjacker appeared to be driven to
commit his extraordinary crime by a combination of
21
 an intense sense of unreality and clear suicidal intent.
Substantial evidence has been accumulated to the ef-
fect that the skyjacker developed an inordinate
awareness of his personal inability to maintain a sta-
ble physical equilibrium, vertically as well as both
on a lateral and on an angular axis. His psychic dise-
quilibrium appears to have clear associative patterns
with his physical disequilibrium... equilibratory de-
fects create great difficulties in achieving psychic ho-
meostasis intrapersonally and interpersonally. (Hub-
bard, 1971, p. 230).
Proprioceptive Function and Praxis
In 1972, Gellhorn related proprioception with emotion
in a cause/effect relationship, stating that propriocep-
tive discharges contribute to the physiological processes
underlying the emotions in two ways: (1) By setting the
hypothalamic balance - determined by the posture of
the body - the total quantity of impulses from the pro-
prio-impulses arriving in the posterior hypothalamus
per unit of time serve as a regulator. (2) By facial expres-
sion - input from contraction patterns leads to afferent
impulses via the hypothalamic-cortical system which in-
teract with the tactile impulses of the expression in the
cortex.
In 1940, Angyal related many of the hallucinations
common in certain types of schizophrenia to a proprio-
ceptive and tactile base. These are often included in
clinical descriptions of the schizophrenic. "The general
behaviour appears odd in many ways: mannerisms, gri-
maces, purposeless acts, stereotyped motions, impulsive
gestures are observed." (Angyal, 1940, p. 616). At times
motion is reported to be exaggerated, at times to be
severely limited. Both can be explained through applica-
tion of sensory integrative theory. Excessive, exagger-
ated or stereotyped motion may increase both vestibular
and proprioceptive input. Severely limiting motion can
be indicative of postural insecurity or tactile defensi-
veness in an adult.
Tactile Function:
A second neurological system central to sensory integra-
tion is the tactile system. Referring to this, Montague
wrote: "Although touch is not itself emotion, its sensory
elements induce those neural, glandular, muscular and
mental changes which, in combination, we call emo-
tion..," He further states that contact (touch) seeking
is the foundation upon which all subsequent behaviour
develops (Montague, 1978, p. 103). Lacombe refers to
the ego as being the perception of the bodily self "...and
what one feels and knows of the body is the skin." (in
Montague, 1978, p. 88). In describing schizophrenia,
Weiner (1958) related tactile failure to estrangement,
uninvolvement, lack of identity, detachment, emotional
shallowness and indifference.
"Another basic characteristic of schizophrenic pa-
tients," states Lidz, "is their tenuous self boundaries
(sometimes termed 'ego boundaries'), which lead to con-
fusions between what arises within the self and what
is outside it and to deficiencies in maintaining the integ-
22
rity and differentiation of the self." (1978, p. 71). He
continues.
The failure to differentiate clearly between self and
non-self which is so characteristic of schizophrenic pa-
tients, is, as Piaget has described, a normal charac-
teristic of the young child. It represents the egocentri-
city of the 'sensori-motor' period and to some degree
the 'preoperational' state of cognitive development...
Overcoming this initial egocentricity is vital to human
development for many reasons but especially for cog-
nitive development because no true category forma-
tion can occur unless the self can be excluded from
a grouping or category, nor can object constancy be
achieved. (Lidz, 1978, p. 81).
The tactile system forms the literal boundary between
the self and non-self, and as such appears vital to the
establishment of individual identity and ego strength.
Present:
As mentioned in the review of basic sensory integrative
theory included earlier, factorial studies have linked
visual-motor problems with dysfunction in the more
basic tactile and vestibular sensory modalities, (Ayres,
1964; Ayres, 1966; Geddes, 1972; Ayres, 1974; Monta-
gue, 1978). Kenny and Rohn, (1979) found that adoles-
cents who attempted suicide showed a significantly
higher incidence of visual-motor problems during psy-
chological testing than did a comparable group of
normal adolescents. Their findings suggested that
unrecognized learning disabilities might be an addi-
tional stress in life which could increase susceptibility
to suicide.
The importance of early sensory stimulation to devel-
opment was shown by Melzack, (1962) who demon-
strated that even mild deprivation of patterned visual
stimuli during early maturation of dogs resulted in
greater difficulty in perceptual discrimination and in the
ability to utilize the discrimination in a new learning
situation. In adult humans sensory deprivation has
resulted in emotional, perceptual, and other behavioural
deterioration. There is repeated reference to lack of
organizing, structuring and relating of the self to objects
and objects to objects, (Solomon, 1961; Silver and
Gabriel, 1964; Gellhorn, 1972; Montague, 1979; Hub-
bard, 1971; Resman, 1981). In a study of mice with
vestibular defects, Douglas (1982) found that there was
a marked increase in vestibular self stimulation, anti-
social behaviour, agressive behaviour, and a decrease in
nuturing and parenting skills. Such studies show results
which appear similar to the clinical picture of the person
with sensory integrative dysfunction and to that of
schizophrenia.
Ornitz (1973) suggested that faulty modulation or
inadequate homeostatic regulation of sensory input, (i.e.
sensory integrative dysfunction), may result in severe
emotional stress and may be the mechanism that pro-
duces hallucinations in schizophrenia. Lerner (1968)
generated and confirmed a hypothesis that in a sample
of schizophrenic patients there is a correspondence in
developmental level between cognitive-perceptual func-
tioning and social effectiveness and that the level of
CJOT - VOL. 51 - NO. I
cognitive-perceptual functioning is predictable from the
level of social effectiveness.
The preceeding authors have connected dysfunction
in the sensory systems primarily targeted in sensory
integrative treatment, or their integration as being highly
involved with emotions, emotional disturbance and
more directly with schizophrenia.
Application
King, (1974) began reporting on the symptoms of senso-
ry integrative dysfunction which she noted in chronic
schizophrenic patients and since then attention has been
focused on the implications this holds for occupational
therapy treatment with this difficult population. The
underlying theoretical concepts for her use of a sensory
integrative approach with this population are based on
the premises that:
1. Schizophrenics often show poor ability to move
automatically (motor plan). This is shown in psychomo-
tor retardation, perseverative behaviours, and disruption
of speech patterns. Motor planning is related to all of
the primary sensory systems considered by Ayres.
(Ayres, 1974, 1974b, 1971).
2. Schizophrenia has often been associated with pos-
tural-vestibular difficulties such as excessive primitive
postural reflex patterns, unstable posture, and postural
insecurity (Ornitz, 1970; Montague, 1978; Douglas,
1982).
3. The vestibular system is in continuous contact with
the limbic system, thus having a potentially strong effect
on the emotions (Schilder, 1933; Barr, 1979; Dimond,
1980; Douglas, 1982).
4. Vestibular and tactile input have a strong effect
on basic arousal levels, even affecting physiological signs
such as blood pressure, heart rate, and respiration
(Ayres, 197~; Barr, 1979; Montague, 1978).
Recent' studies with adult schizophrenics have shown
sensory integration treatment as effective in promoting
verbalization, gait and posture, body scheme and on
a short term, decreasing overt psychotic behaviour. Most
of these studies were short, with treatment being given
for an average of six weeks. None of these studies were
designed with a control group to control for the possible
biasing of the Hawthorne effect, and all were done with
less than ten subjects participating, (King, 1976; Levine,
1977; Rider, 1978; Leville, 1981).
At the present time, several facilities in Ontario are
considering establishing a sensory integration program
for their chronic schizophrenic population. One such
program is found at Whitby Psychiatric Hospital (WPH).
WPH is a large facility, serving urban and rural areas
and both an acute and chronic psychiatric population.
The sensory integration program is an outgrowth of the
occupational therapy assessment unit, organized in 1977.
By 1978 it was operating as a separate speciality area.
Currently the program is comprised of three treatment
groups, individual treatment sessions and assessment,
which utilize the Bruininks-Oseretsky Test of Motor
Proficiency, the Purdue Perceptual Motor Survey, the
Southern California Sensory Integration Test, the
FEBRUARYIFEVRIER 1984
Southern California Postrotary Nystagmus Test, and
clinical observations as suggested by Dr. Ayres. (1974).
In the fall of 1981 a review of the sensory integration
program participants was undertaken in which results
from pre and post treatment assessments (Bruininks-
Oseretsky and Purdue), were analyzed and compared
with similar testing of non-treated patients with an
eleven month interval between pre- and post- testings.
The results of this analysis highlighted a number of
significant trends. In particular, the treatment group
consistently improved on the two measures utilized while
the non-treated group had instances of decreased or
stagnated function. This improvement in the treatment
group approached statistical significance in the fine
motor function composite and the battery composite of
the Bruininks-Oseretsky test and in all three sections
of the Purdue battery.
In comparing the two groups after the eleven month
time span, (between initial and post-test), the treatment
group had improved more than the non-treatment
group to a degree which approached statistical signifi-
cance on four measures; the Bruininks- Oseretsky gross
motor composite, upper limb co-ordination measure and
battery composite, and the Purdue perceptual-motor
match task. It is felt that with a larger group size, and
the resultant smaller standard deviation, statistical sig-
nificance would be achieved on these measures.
Future:
Many indicators point to the possibility of a sensory
integrative basis for chronic schizophrenia, ranging from
literature published in 1811 to more recent works. Due
to the subjective nature and multitude of confounds
associated with many of these indicators, the immediate
future holds primarily the promise of increased struc-
tured research aimed at developing a more definitive
statement regarding the nature of chronic schizophrenia
and its relationship to sensory integration.
The application of sensory integrative theory to
chronic schizophrenia offers a possible explanation for
variabilities observed in this confusing diagnostic cate-
gory. Differing symptomatology may be related to dys-
function in different sensory systems or in the way they
interact. It is possible that the difference between reac-
tive and chronic schizophrenia is related to the strength
with which the basis of sensory integrative function has
been formed. With stress, a stronger system may collapse
and then re-integrate, whereas a weaker system may
be unable to do so, and deteriorate further.
In the longterm, if the connection postulated is sup-
ported through research, two major benefits will be
accrued. Firstly, this will serve as the foundation for
the development of a non-invasive treatment modality
for a most difficult clientele, and secondly, this may aid
in the development of preventative strategies. With the
early recognition of sensory integrative difficulties and
a greater knowledge of the implications this holds for
the individual it may be possible, through early inter-
vention, to decrease the incidence of process schi-
zophrenia in future generations.
23
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Resume
Cet article a pour but de definir brievement ce qu'est l'integration des sens telle qu'expliquee par Ie
Dr. A. Jean Ayres, mettant en valeur les cas type les plus communs de malfonction. Par une recherche
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I'Hopital Psychiatrique de Whitby en 1981.
Les possibilites de traitements et recherches a venir sont egalement etudiees,
24
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Acknowledgements
We would like to offer sincere thanks to all of the staff at Whitby
who were of assistance to us in the preparation of this paper, in
particular to the research advisory committee, Joyce Pierdon, Chief
of Occupational Therapy Service, and to Marcel Vandyke, R.N. for
her services in translation.
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